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Current and Future Models of Integrated Care

Andrew J. McLean, MD, MPHMedical Director, ND Department of Human ServicesChair, Department of Psychiatry and Behavioral ScienceUND School of Medicine and Health Sciences

Pam Sagness, DirectorBehavioral Health DivisionND Department of Human Services

Objectives

• After completing this session, the participant/learner will be able to…

1) Understand the concept of integrated care

2) Identify current models of integrated care being utilized in the region

3) Identify models of integrated care that may be utilized in the region in the future.

Defining Behavioral Health

Behavioral Health is an umbrella term for care that addresses any behavioral problems impacting health, including mental health and substance abuse conditions, stress-linked physical symptoms, patient activation and health behaviors. The job of all kinds of care settings, and done by clinicians and health coaches of various disciplines or training.

3Source: Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

Major Categories:• Neurodevelopmental Disorders

• Schizophrenia Spectrum and Other Psychotic Disorders

• Bipolar and Related Disorders

• Depressive Disorders

• Anxiety Disorders

• Obsessive Compulsive and Related Disorders

• Personality Disorders

• Neurocognitive Disorders

• Addictions and Related Disorders

• Trauma and Stressor Related Disorders

• Dissociative Disorders

• Somatic Symptom and Related Disorders

• Feeding and Eating Disorders

• Sleep-Wake Disorders

• Sexual Dysfunctions

• Gender Dysphoria

• Disruptive, Impulse Control, andConduct Disorders

• Paraphilic Disorders

Why is this an issue?• 67% of individuals with a behavioral health disorder do

not get behavioral health treatment1

• 30-50% of referrals to behavioral health from primary care don’t make first appt2,3

• Two-thirds of primary care physicians reported not being able to access outpatient behavioral health for their patients4

due to:• Shortages of mental health care providers• Health plan barriers• Lack of coverage or inadequate coverage

• Depression goes undetected in >50% of primary care patients5

• Only 20-40% of patients improve substantially in 6 months without specialty assistance6

Sources: 1Kessler et al., NEJM. 2005;352:515-23. 2Fisher & Ransom, Arch Intern Med. 1997;6:324-333. 3Hoge et al., JAMA. 2006;95:1023-1032. 4Cunningham, Health Affairs. 2009; 3:w490-w501. 5Mitchell et al. Lancet, 2009; 374:609-619. 6Schulberg et al. Arch Gen Psych. 1996; 53:913-919

Study reviewing Health Risk data and cardiac disease

• Tobacco use• Hypertension• Obesity • Elevated cholesterol • High blood glucose • Sedentary lifestyle• Stress• Depression• Excessive use of alcohol

• #1 ?

• #2 ?

J Occup Environ Med 2001 May;43(3):201.

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• Low physical Activity

• Poor nutrition

• Excessive alcohol use

• Sleep

• Tobacco use

Modifiable Health Risk Behaviors

MEMORY

FOCUS

ACTION

Assisting in health behavior change

• MOTIVATIONAL INTERVIEWING:• It is based on 4 core principles:

• Express empathy (i.e, lecturing/shame doesn’t work…)

• Develop discrepancy (between current and desired behavior-change takes time)

• Roll with resistance (everyone is ambivalent)

• Support self-efficacy (individual autonomy)

Variables re: behavioral health in primary care

• Emergent

• Urgent

• Routine/Chronic Disease Management*

• Illness/Behavior

• Severity

• Supports

Question:

• According to Psychiatric Services (2009),

roughly ____% of psychotropic medications prescribed by physicians are prescribed by non-psychiatrists.• 35%• 50%• 65%• 80%

Ballpark….# of psychotropics frequently seen in primary care:• Antidepressants: 15• Mood stabilizers: 7• Antipsychotics: 12• ADHD meds: 10• Alzheimer’s meds: 4• Sleep meds: 5• Anti-anxiety meds: 7• 60

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So, what are our options?

1) Business as usual…

2) Screening

3) Consultation

4) Co-location

5) Collaboration

To Fractionate, or Not to Fractionate: That is the Question

Preikestolen

What is “Integrated Care?”• “the systematic coordination of general and behavioral healthcare.”

Many of Integrated Care Models-However…

• Behavioral Health in Primary Care. (By far far far the most common)

• Primary Care in Mental Health

• Primary Care in Behavioral Health

State Examples• California: The Integrated Behavioral Health Project (IBHP)

• The Massachusetts Child Psychiatry Access Project (MCPAP)

• DIAMOND (Depression Improvement Across Minnesota Offering a New Direction)

• Missouri: Community Mental Health Case Management (CMHCM)

• ICARE Partnership North Carolina Project

• Tennessee: Cherokee Health Systems Model

• Vermont Blueprint for Health

• Washington IMPACT program

Integration: An Evolving Relationship

18 Source: http://uwaims.org

Consultative Model• Psychiatrists sees patients in consultation in

his/her office – away from primary care

Co-located Model• Psychiatrist sees patients in primary care

Collaborative Model• Psychiatrist provides caseload consultation about

primary care patients; works closely with primary care providers (PCPs) and other primary care-based behavioral health providers (BHP)

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Patient-Centered Medical Home A PCMH is not a PCMH without Behavioral Health

Patient-Centered Care Teams• Team-based care: effective collaboration between PCPs and Behavioral Health Providers.• Nurses, social workers, psychologists, psychiatrists, licensed counselors, pharmacists, and

medical assistants can all play an important role.

Population-Based Care• Behavioral health patients tracked in a registry: no one ‘falls through the cracks’.

Measurement-Based “Treat to Target”• Measurable treatment goals clearly defined and tracked for each patient.• Treatments are actively changed until the clinical goals are achieved – “treat to target”.

Evidence-Based Care• Treatments used are ‘evidence-based’.• Pharmacology, brief psychotherapeutic interventions, models.

Core Principles of Effective Collaborative Care

Source: http://uwaims.org19

Collaborative Care• Collaborative Care is a specific type of integrated care

that operationalizes the principles of the chronic care model to improve access to evidence based mental health treatments for primary care patients.

• Collaborative Care is: ▫ Team-driven collaboration and Patient-centered▫ Evidence-based and practice-tested care▫ Measurement-guided treatment to target▫ Population-focused

▫ Accountable care

http://aims.uw.edu

Collaborative Care

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Collaborative care optimizes all behavioral health resources

Source: http://uwaims.org

“Sweet” Spot for the Collaborative Care Model

• Issues with depression and substance abuse must be pre-empted, rather than treated once advanced.

• Goal is to detect early and apply early interventions to prevent from getting more severe

NoneMild

Moderate

Severe

Target Population

Health Management Associates/L. Raney

Stepped Care Approach

1o Care

Psychiatricconsult(Face-to-face)

PsychiatricInpatienttx

Self-Management

1° Care+BHP

BHspecialtyshorttermtx

BHspecialtylongtermtx

Psychiatric Consultation

• Uses limited resources to their greatest effect on a population basis

• Different people require different levels of care

• Finding the right level of care often depends on monitoring outcomes

• Increases effectiveness and lowers costs overall

Van Korff et al 2000

Recent add for a “consulting psychiatrist”

• Essential Duties and Responsibilities:• · Provide regularly scheduled consultation to participating primary care practices. Consultations will

focus primarily on patients who are new to behavioral health treatment or who are not improving as expected.

• · Provide phone consultation to primary care physicians (PCPs) as requested. Response time should be within 24 hours for low priority calls and 1-2 hours for urgent calls, if possible, within normal working hours.

• · Work with participating practices to track and oversee patient outcomes using an integrated health model.

• · Suggest treatment plan changes including medication recommendations for patients.• · Discuss patients who may need referral for additional behavioral health care and advise on

treatment plans during the transition period to ensure continuity of care.• · Utilize electronic medical record (EMR) of the primary care practices to document patient

information, referrals or other relevant information as required.• · Adhere to all compliance procedures relevant to protected health information (PHI) and HIPAA

regulations.• · Communicate clearly to PCPs, care coordinators, or other designated contacts for the practices

regarding limitations of consultation and treatment recommendations, if relevant.• · Maintain communication flow in relevant e-mail systems including a response time within 2

business days generally. Urgent e-mail should be responded to as soon as possible.• · Participate in weekly, monthly, or quarterly consult meetings as assigned.• · Provide on-site time at each participating practice at least monthly. On-site work may include

meeting PCPs, care coordinators, or other designated staff, discussing procedures and coordinating services, provider education, case presentation, and in-person evaluation of patients.

• · Participate in and/or provide training related to this position.

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Caseload ReviewMRN Name Status Date

follow up due

Actual contact

PHQ-9 % change

GAD-7 % change

1236 RobertSled

Active 2/1/17 2/4/17 15 0% 11 0%

2/15/17 2/15/17 13 -13% 11 0%

3/9/17 3/10/17 15 0 9 -18%

3/23/17 3/23/17 13 -13% 6 -45%

4/6/17 4/7/17 12 -20% 7 -36%

4/20/17 4/20/17 11 -27% 7 -36%

5/04/17 5/04/17 9 -40% 6 -45%

https://aims.uw.edu/resource-library/patient-tracking-spreadsheet-example-data

Disciplines-(examples)not all-inclusive…

• RNs• LPNs• APRNs• Social Workers• Therapists• Psychologists• LACs• Physicians• PA-Cs• OTs• PTs

What type of individual does it take for this type of model to be successful?

• Fill in the blank__________________________

We couldn’t possibly…

So, all parties must be flexible

• Who is usually the Behavioral Health Care Manager?

MSW, LCSW, MA, RN

• If also a behavioral health provider, can be PhD, PsyD, LAC, etc..

SBIRT(screening, brief intervention, referral to treatment)

• SBIRT CONSISTS OF THREE MAJOR COMPONENTS:

• Screening — a healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools. Screening can occur in any healthcare setting

• Brief Intervention — a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice

• Referral to Treatment — a healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services

• http://www.integration.samhsa.gov/clinical-practice/SBIRT

Screening ToolsFind one you are comfortable with, such as:• (for substance use/SBIRT):

AUDIT, MAST, CAGE-AID, ASSIST

• PHQ-2/9 Symptom Checklist

• GAD-7

• Mood Disorder Questionnaire

• AIMS

• Reporting and collaboration (NOMs/PQRS/NCQA)

• Many of the must-pass elements are behavioral health:

-Practice Team (Team-Based Care)-Use Data for Population Mgt.-Care Planning and Self-Care Support-Referral Tracking and Follow-up-Implement Continuous Quality

Improvement

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Ebell M. Am Fam Physician. 2004 May 15;69(10):2421-2422.

Point of Care Guide

Same Day Services:

• Mental health care services (which, under the Medicare Program, includes treatment for substance use disorder);

• Alcohol and/or substance (other than tobacco) abuse structured assessment, and intervention services (SBIRT services) billed under HCPCS codes G0396 and G0397; and

• Primary health care services.• Medicare Part B pays for reasonable and necessary integrated

health care services when they are furnished on the same day, to the same patient, by the same professional or a different professional. This is regardless of whether the professionals are in the same or different locations.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mental-Health-Services-Booklet-ICN903195.pdf

What is the Future Looking Like?Telemedicine

• Setting• Equipment• Credentialing• Services• Payment

Telemedicine and Collaborative Care

Self Management

EducationProject ECHO

e-ConsultCurbside

Consultation Registry Review Telepsychiatry

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CoCMCase-based Learning

for PCPs Virtual Visit

Text messagingRemote monitoringApps – BA, reminders, fitnessOnline CBT

PediatricAssessLines (PALs)

Didactic each timeCase presentations –by “spokes”Expert “Hub”

Patient Guided

OnlineTasking Offsite

With thanks to Lori Raney, MD and Health Management Associates

Popular Model

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Mental Health Start-Up Companies

• 6 months ago: around 250

• As of this week, 353

• Is there an app for that?

Will this

• Increase demand in your office by increasing awareness?

• Reduce demand by allowing other access from other treatment providers?

• Complicate care due to lack of information sharing, or lack of evidence-based treatment?

Data and communication

•HIPAA

•42 CFR(2)

Resources

http://www.sprc.org/for-providers/primary-care-tool-kit

Questions, thoughts?